First Name:
Last Name
Specialty:
Sub-Specialty:
Hometown:
Intended Practice Area:

Region:
NorthEast
NorthWest
Midwest
SouthEast
SouthWest

Community Size (preference)
Major Metro Area (Downtown) Over 1 Million Over 500K Suburban Area Small City (50-200K) Rural Community (<50K)

Which community amenities
are most important to you?
(select all that apply)
Restaurants
Cultural Events
Shopping
Schools
Sporting Events
Parks and Recreation
Other Amenities:

What is your ideal practice opportunity? MSG SSG Private Solo HMO-PPO Urgent Care

What size group do you prefer? Small (1-4) Medium (5-10) Large (10+)

Do you wish to have equity in a practice? Yes No

How often would you prefer call? No Call 1:2 or better 1:3 or better 1:4 or better 1:5 or better 1:6 or better 1:7 or better Doesn't Matter

Do you plan to follow your patients through inpatient hospital care? Yes No

What type of demographics to you wish to see in your practice? Pediatrics Adult Inner City population Spanish Speaking Private Pay Geriatric Other

In considering a practice opportunity, what 3 factors would be most important to you?
Location
Call Schedule
Colleagues
Similar Medical Philosophies
Office/Hospital Facilities
Salary
Loan Repayment
Lifestyle Considerations
Patient Demographics
Other:

Where did you complete your undergraduate degree?

What was your major?

What year did you graduate?

Where did you attend medical school?

What year did you graduate?

What residency program did you attend?

Which Specialty?

Year Completed?

Did you complete any Fellowships? Yes No
If yes, please specify:


Please list any additional training you have.


Are you Board Certified? Yes No

If no, are you Board eligible? Yes No

In which states are you licensed?


Please specify any previous practice experiences and dates of employment.


What are your hobbies/interests?


When and where is best to contact you?
Home Phone
Work Phone
Pager
Cell Phone
E-Mail

What is your mailing address?